Ms. GM Is A 48-Year-Old With Type II Diabetes Using Cassia C ✓ Solved

Ms. GM is a 48-year-old with Type II Diabetes using cassia c

Ms. GM is a 48-year-old with Type II Diabetes using cassia cinnamon and ginseng while prescribed Aricept and Coumadin. Is there any additional subjective or objective information you need for this client? Explain. What is your position on Ms. GM's use of alternative supplements for her diabetes and memory? Explain and include contraindications. Are there any additional tests or assessments you would complete for this patient given this list of medications? Explain. How might your treatment plan, in terms of medications, differ for this patient? Include medication class, mechanism of action, route, half-life, metabolism and elimination, contraindications, and black box warnings. What health maintenance or preventive education is important for this client based on your chosen medication/treatment?

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Additional subjective and objective information needed

Key subjective information to obtain includes detailed medication and supplement history (dose, frequency, formulation, start date, brand of cassia cinnamon and ginseng), history of prior bleeding or clotting events, hypoglycemia symptoms and episodes, current prescription diabetes therapy (if any), alcohol and tobacco use, over-the-counter medications (especially NSAIDs, aspirin, herbal teas), and history of cardiac conduction problems, syncope, ulcers, or asthma (relevant to donepezil) (Izzo & Ernst, 2009; NCCIH, 2020a).

Objective data should include vital signs (with attention to heart rate and orthostatic changes), focused cardiovascular and neurological exams, baseline cognitive testing (MMSE or MoCA), baseline and periodic laboratory assessments: INR, CBC (for bleeding/anemia), fasting plasma glucose and HbA1c, basic metabolic panel including serum creatinine and estimated GFR, and liver function tests (AST/ALT) because herbal products and prescription drugs can affect hepatic metabolism (FDA, 2018; FDA, 2017). An ECG is advisable if bradycardia, syncope, or conduction disease is suspected given donepezil’s potential to slow heart rate (Aricept label).

Position on use of cassia cinnamon and ginseng — risks and contraindications

Cassia cinnamon contains appreciable amounts of coumarin, which can potentiate anticoagulation and increase bleeding risk when taken with warfarin (Coumadin) (NCCIH, 2020b; Izzo & Ernst, 2009). Cassia also has modest glucose-lowering effects, which could increase risk of hypoglycemia if used with other glucose-lowering agents (Akilen et al., 2012). Given Ms. GM’s concurrent warfarin therapy, I would advise caution and recommend discontinuation of cassia cinnamon or substitution with a low-coumarin Ceylon cinnamon only after discussion with the anticoagulation provider and with close INR monitoring (FDA, 2018; NCCIH, 2020b).

Ginseng has been associated with variable effects on warfarin (reports of reduced INR) and can also lower blood glucose, potentially causing hypoglycemia in patients with diabetes or those on antidiabetic drugs (NCCIH, 2020a; Izzo & Ernst, 2009). There are case reports of herb–drug interactions between ginseng and anticoagulants and inconsistent effects on platelet function and CYP metabolism. Additionally, ginseng’s stimulant properties and potential cholinergic modulation warrant caution in patients on acetylcholinesterase inhibitors (donepezil/Aricept) because of unpredictable additive or opposing CNS effects (Izzo & Ernst, 2009). Therefore, I would recommend discussing cessation of ginseng with the patient and her prescribing clinicians until interactions have been evaluated and risks are clarified.

Additional tests and assessments

Immediate tests: INR and CBC (to evaluate baseline anticoagulation and bleeding risk), fasting glucose and HbA1c (to quantify glycemic control), comprehensive metabolic panel with renal and hepatic function (to assess drug clearance risks) (FDA, 2018; Akilen et al., 2012). Assess baseline cognition (MMSE/MoCA) and functional status, and obtain an ECG if there is history of bradyarrhythmia or syncope because donepezil can exacerbate bradycardia or conduction abnormalities (Aricept label).

Medication reconciliation with pharmacy records and consultation with the anticoagulation clinic (if applicable) is critical. If warfarin is difficult to stabilize due to herbal use, consider specialist input regarding alternative anticoagulation options, with attention to renal function and drug interactions (Holbrook et al., 2012).

Treatment plan considerations and pharmacology

Diabetes management: First-line pharmacotherapy for most patients with Type 2 diabetes is metformin (class: biguanide). Mechanism: decreases hepatic gluconeogenesis and improves peripheral insulin sensitivity. Route: oral. Typical half-life: ~4–8 hours (plasma), but pharmacodynamic effects persist; metformin is not metabolized and is excreted unchanged by the kidneys (renal tubular secretion) (Rena, Hardie, & Pearson, 2017). Contraindications: significant renal impairment (eGFR

Rationale: If Ms. GM is not already on pharmacologic therapy, initiating evidence-based therapy (e.g., metformin) would be preferred over unregulated cassia cinnamon because of predictable efficacy, safety profile, and clear monitoring parameters. If she is on other glucose-lowering drugs, consider potential interactions with cinnamon/ginseng and counsel accordingly (Akilen et al., 2012).

Memory treatment: Aricept (donepezil) class: acetylcholinesterase inhibitor. Mechanism: reversible inhibition of acetylcholinesterase, increasing acetylcholine levels in CNS. Route: oral. Half-life: approximately 70 hours (steady-state achieved approximately 15–21 days). Metabolism: hepatic via CYP2D6 and CYP3A4 with renal and biliary excretion of metabolites (Aricept label). Contraindications: hypersensitivity to donepezil. Important precautions: may exacerbate bradycardia, syncope, GI bleeding or bronchospasm (no FDA black box specific to donepezil, but cardiac and pulmonary precautions apply) (FDA, 2017).

Anticoagulation: Warfarin (Coumadin) class: vitamin K antagonist. Mechanism: inhibits vitamin K epoxide reductase complex 1 (VKORC1), decreasing synthesis of vitamin K–dependent clotting factors. Route: oral. Half-life: varies by enantiomer, effective clinical half-life approx. 36–42 hours. Metabolism: hepatic via CYP enzymes (notably CYP2C9); elimination via hepatic metabolism and renal excretion of metabolites. Contraindications: hemorrhagic tendencies, recent or contemplated surgical procedures with high bleeding risk, severe uncontrolled hypertension; black box warning: major or fatal bleeding can occur during therapy (Coumadin label) (FDA, 2018).

Clinical implications: Because cassia cinnamon contains coumarin-like compounds and ginseng may alter warfarin effect, Ms. GM’s INR could be unstable. The immediate plan is to obtain INR and counsel discontinuation of cassia cinnamon and ginseng until interactions are assessed; coordinate with anticoagulation clinic. If anticoagulation alternatives are considered (direct oral anticoagulants), assess renal function and drug interaction profile; discuss risks/benefits with the patient and cardiology/hematology as appropriate (Holbrook et al., 2012).

Health maintenance and preventive education

Educate Ms. GM about the risks of herbal supplements when taken with prescription medications: specifically, the bleeding risk of cassia cinnamon with warfarin and variable effects of ginseng on INR and blood glucose (NCCIH, 2020a; NCCIH, 2020b). Emphasize consistent diet regarding vitamin K intake, avoidance of NSAIDs/aspirin unless approved, prompt reporting of bleeding/bruising, and carrying information about all supplements and medications. Teach home glucose monitoring and recognition/management of hypoglycemia, and the importance of scheduled INR checks until values stabilize after any supplement change. For donepezil, counsel on possible bradycardia/syncope, GI symptoms, and to report new dizziness, syncope, or signs of GI bleeding (Aricept label; FDA, 2018).

Coordinate care with Ms. GM’s primary care clinician, anticoagulation service, and pharmacists. Document all supplements in the chart and encourage open dialogue about nonprescription therapies. Shared decision-making, close laboratory surveillance (INR, HbA1c, renal function), and cessation of high-risk supplements until cleared by her providers is the safest approach.

References

• Akilen, R., Tsiami, A., Devendra, D., & Robinson, N. (2012). Cinnamon in glycaemic control: Systematic review and meta-analysis. Diabetes, Obesity and Metabolism, 14(3), 217–232.
• Aricept (donepezil) [prescribing information]. (2017). Eisai Inc.
• Coumadin (warfarin sodium) [prescribing information]. (2018). U.S. Food and Drug Administration.
• FDA. (n.d.). Metformin hydrochloride [prescribing information]. U.S. Food and Drug Administration.
• Holbrook, A., et al. (2012). Evidence-based management of anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis. Chest, 141(2 Suppl), e152S–e184S.
• Izzo, A. A., & Ernst, E. (2009). Interactions between herbal medicines and prescribed drugs: A systematic review. Drugs, 69(13), 1777–1798.
• National Center for Complementary and Integrative Health. (2020a). Ginseng. U.S. Department of Health and Human Services. https://www.nccih.nih.gov
• National Center for Complementary and Integrative Health. (2020b). Cinnamon. U.S. Department of Health and Human Services. https://www.nccih.nih.gov
• Rena, G., Hardie, D. G., & Pearson, E. R. (2017). The mechanisms of action of metformin. Nature Reviews Endocrinology, 13(9), 569–579.
• Weitz, J. I., et al. (2015). Practical guidance for the use of warfarin and direct oral anticoagulants. Journal of Thrombosis and Haemostasis, 13(Suppl 1), S388–S391.